Medical school - the later years 2

8 Medical school: the later years As the medical student progresses through into their third year and beyond, increasing amounts of time are spent in the various clinical teaching settings and less in the classroom The white coat is donned, and the shiny new stethoscope is placed ostentatiously in the pocket, usually alongside numerous pocket-sized textbooks, pens, notepads, and sweet wrappers Most students by now have some experience of listening and talking to patients and of the hospital wards The sight of the ill patient in a bed does not come as the awful surprise it did to generations of medical students who spent their first years cocooned in the medical school The style of teaching changes emphasis, becoming more of an apprenticeship but retaining the academic backup of lectures, seminars, and particularly tutorials More of the course is taught by clinical staff: consultants, general practitioners (GP), and junior doctors, often in small groups at the bedside, on dedicated teaching rounds or in tutorials, in the operating theatre, in the outpatient clinic, or general practice surgery Teaching also takes place at clinical meetings or grand rounds and the firm’s regular radiology meeting (when the week’s X-ray pictures and scans are reviewed and discussed with a radiologist) and histopathology meeting (when the results of tissue biopsies and postmortem examinations are discussed) Some students find the change in the style of teaching frustrating as much time seems to be wasted hanging around waiting for teaching that never seems to happen The registrar or consultant who is due to be teaching is often delayed in theatre with a difficult case or still has a queue of patients waiting in the outpatient clinic Many of these doctors are fitting in their teaching commitments around 101 102 Learning medicine an already punishing clinical workload, and so often a combination of better organisation by the schools and some initiative in self-directed learning from the students is all that is needed to extract the value from such a valuable educational source It may well be that with so much to learn, insufficient attention is given to the formation of attitudes It is said that medical students have more appropriate attitudes to both patients and to others with whom they share care when they enter medical school than when they qualify as doctors There may be more than a grain of truth in this In the Bristol report, Professor Sir Ian Kennedy expressed the view that “the education and training of all health care professionals should be imbued with the idea of partnership … (with) … the patient … whereby the patient and the professional meet as equals” As far as mutual respect in teamwork is concerned, opportunities for learning together (multidisciplinary learning), both in the undergraduate and postgraduate years, are not fully exploited Much can be learned from reasonable complaints A patient who had complained about the attitude of his surgeon was interviewed by another surgeon as part of a formal investigation into the complaint The patient was pleased to find that the investigating surgeon was a complete contrast – “conversational, sympathetic, and informative; wide ranging and encouraged 103 Medical school: the later years questions (with) a very human approach which inspired trust” As the complainant explained, the matter need never have reached the stage of formal complaint: all he had been seeking was “a small acceptance (from the first surgeon) that some of the procedures are inadequate and will be revised” Arrogance is something that students need to lose early in their training, if they have the misfortune to be afflicted by it; patients can without it First patients Stepping tentatively on to the ward for the first time, resplendent in my new white coat, I felt that the long awaited moment had arrived “Clerking” involves taking a history from and examining the patient We had been told that this process, which has been handed down from doctor to medical student for countless generations, enables the doctor to make 95% of the diagnosis (75% from the history and a further 20% from the examination – the last 5% comes from further investigations) This is why clerking has and will continue to be such a powerful tool in the hands of the clinician, though not necessarily in the hands of a junior clinical student On the first day of the junior course we learn how to take a thorough history This involves an overall framework of “presenting complaint”, “history of presenting complaint”, “past medical history”, “family history”, “drug history”, “social history”, and “any other information” With practice it becomes possible to tailor the history taking to the individual Next comes the examination, something which opens up a veritable minefield for the inexperienced When you perform a general examination every body system has to be inspected, palpated (lightly and deeply), percussed (examined by tapping with the fingers and listening to the pitch of the sound produced), and auscultated (listened to with a stethoscope) This is the theory but inevitably, either through incompetence or sheer bad luck, it is almost impossible to perform a perfect examination on every patient: some of the pulses are not felt or the enlarged liver does not seem that enlarged; whatever the sign of disease that causes such frustration by escaping the student, you can guarantee that the senior house officer will come along and find it within seconds! The introduction to basic surgical techniques was one of the better activities organised for us during the junior clinical course Armed with scalpels, sutures, forceps, and pigs’ trotters the surgeons demonstrated the basic principles of stitching wounds and then let us loose on our own practice limbs This was an excellent afternoon for the students, not least because it gave us the opportunity to something incredibly practical that most of us had never done before Having mastered (?) the mattress stitch, we moved on to the more cosmetically friendly subcuticular stitch, and I am sure we greatly impressed our surgical superiors with our manual dexterity! 104 Learning medicine The afternoon concluded with teaching us how to draw up and mix drugs with a syringe and how to inject them subcutaneously and intramuscularly (the intramuscular route was cleverly improvised with an orange) My first firm was a series of firsts First clerking of a patient – nerve racking as the whole scenario is new I felt ill equipped and slightly obtrusive as I clumsily searched, questioned, and of course palpated and percussed my patient The sense of relief as I parted the curtains and left the cubicle, history complete, was overwhelming First ward round – how I regretted not learning my anatomy better as in the words of our senior registrar I displayed “chasms of ignorance”, only managing to redeem myself by the narrowest of margins First surgical operation – it was a real privilege to clerk a patient, then later watch and even assist in the operation and later still revisit the patient on the ward Theatre also provided a superb way to learn by watching but also by the excellent active teaching of the surgeons First freedom – for the first time since entering medical school I was expected to decide for myself where to go to, what to learn, what to read, and to think more laterally and broadly than ever before First encounter with real patients with lives we are able to be part of for some small time – call us naive and overenthusiastic and we would agree We are sure that some of the novelty will wear off after nights on take and unpleasant patients Call us idealistic and we would agree and pray that it may be a comment levelled at us not just now as we experience our “firsts” but on until we experience our very “lasts” When idealism dies it is not replaced by realism but by cynicism and long may we be idealistic realists AH, SC Meanwhile, at another medical school, another student was seeing a similar experience through somewhat different eyes First clinical “firm” The first day as a clinical student is a little like the first time you have sex There is a lot of anxiety and excitement for what often ends up as a disappointing and humiliating experience At last an escape from lecture halls and seminar rooms; an end to being force fed mind numbing facts such as the course of the left recurrent laryngeal nerve or the intricacies of gluconeogenesis I had a crisp white coat and smart matching shirt and tie The finishing touch being a stethoscope slung casually around my neck I had arrived, I looked fantastic, and I was IT 105 Medical school: the later years I was attached to a firm run by a consultant whose fearsome reputation was unrivalled in the region She had a moustache that Stalin would have been proud of and a personality to match My fellow students were a real mixed bag; two rugby lads, two sloanes, a girly swot, a computer geek, and a goth! Most medical students wear a common uniform; boys in light blue shirts, stripy ties (preferably rugby ties), chinos (regulation length one inch too short), and either shiny, pointy shoes or those brown deck shoe things Girls tend to opt for simple blouses with pretty necklines and floaty, flowery, shapeless skirts … invariably sensible and never fashionable Every aspect of being a clinical student combines in an attempt both to educate you and to expose you to the realities of being a junior doctor The time is split between seeing patients on the wards, teaching sessions, sitting in clinics, and assisting in operating theatres The day usually begins with a ward round Medicine is like a huge machine; everyone has an allocated role; everyone is an essential moving part The system works well if we all know our place and act according to our roles The ward round reflects this system and demonstrates the hierarchy and tradition that exists in medicine The consultant is the boss His (or less commonly her) role is twofold Firstly, to impart knowledge to the more junior members of the team (that is, everyone) in the form of witty and wise anecdotes and, secondly, to use derision, disapproval or oldfashioned humiliation on his or her juniors lest they forget their places Next in line are the registrars who are occasionally allowed to adopt the role of the consultant if he or she is otherwise engaged at the golf course/race course/Harley Street Very rarely registrars are allowed to know something the consultant doesn’t There are strict limitations on what this information can be, but it generally involves very obscure areas of research that will never make it into the textbooks anyway! The senior house officers and house officers ensure the smooth running of the firm; taking notes, making lists, organising tests, and collecting results They are also objects for ritual humiliation (that is, teaching) when the students are not around Your role as a student is not difficult; laugh at the consultant’s jokes, help out when needed, learn lots, and make great tea I was strangely reassured to find that ward rounds conformed to my preconceived idea of an all powerful consultant sweeping down the ward with an entourage of doctors and students following in order of decreasing seniority Each student is allocated their own patients On this particular day, my luck is in; the procession stops at the bedside of a young asthmatic man with a chest infection He is not my patient The student concerned steps forward, a little flushed and sweaty, but none-the-less does a good job of presenting her case and answers well under interrogation from the consultant Her triumph, however, is short lived It is revealed that she has not looked in the patient’s sputum pot for days This is just short of a hanging offence on a respiratory firm! 106 Learning medicine There are a number of skills that make life as a medical student more tolerable Most of these involve creating the impression that you know more than you actually This means avoiding answering questions about which you know nothing (which at the beginning is most things) Consider the ritual of bedside teaching I made it my mission to avoid speaking to or touching the patients at all costs Avoiding eye contact is a guaranteed way to be asked a question! All patients are examined from the right hand side, therefore initially it is advisable to stand on the left hand side of the patient One needs to judge the time accurately, however, when the clinician will try to be cunning and ask the student standing the furthest away from the patient The skilled student will anticipate this moment and, at the appropriate time, enthusiastically stands on the right of the patient, hence double bluffing the clinician When successful this manoeuvre is poetry in motion After clinic I went to the casualty department, as it was my turn to shadow the house officer on call This turns out to be highly enjoyable; seeing real patients with real diseases and being involved in the process of sorting them out without the responsibility of having to know things or make decisions In the space of a few hours we see two old ladies with chest infections, a man with heart failure, two paracetamol overdoses, and a heart attack A moment’s peace some or hours later is shattered by a series of piercing bleeps and a crackling disjointed voice proclaims from the house officer’s pocket that there has been a cardiac arrest on one of the wards The dreaded crash bleep: we get up, and we run We arrive on the ward, and very quickly there is a small crowd of doctors and nurses around the bed of the old man we had admitted earlier with a heart attack I stand back feeling more than a little useless Intrigued and a little appalled, I watch as the registrar gives instructions to insert lines and tubes and to administer drugs and electric shocks After about 20 minutes everything stops; a stillness replaces the activity and the old gentleman is left to rest in peace I feel upset and shocked, but to everyone else it’s just part of the job The clinical years are the first real opportunity to manage your own time It is important to so sensibly The system is open to abuse and many a cunning student manages to the minimum amount of work in the shortest period of time There will be things you love about being a student and things you’ll hate I personally would avoid operating theatres like the plague There is nothing pleasant about standing around in green pyjamas, a paper shower cap, and fetid, communal shoes in which most decent people would not even grow mushrooms, never mind put their feet The student in theatre is meant to retract This involves pulling very hard on metal implements (which are usually inserted in a stranger’s abdomen) in directions that your body was not designed to go This causes pain, stiffness, and eventually loss of sensation in the hands, the likes of which have never been felt before outside a Siberian salt mine It is important to learn the things you need to get through the examinations, 107 Medical school: the later years but there are a lot of other valuable lessons to learn One day you will be a house officer and your social life and sanity will be seriously compromised … so don’t waste the time you have now Medicine is great, with something to appeal to everyone It’s a little like a pomegranate: you will hopefully find it satisfying and worth while in the end, but it can be challenging and infuriating going through the process! MB Self-directed learning plays an ever increasing part as time goes on through the course and as you will be repeatedly reminded “every patient is a learning opportunity” There are always patients to be clerked and examined This may be in the holistic mould of learning about the person, their condition, and the whole experience of their illness or learning the clinical features and management of the diseases relating to the speciality you are currently studying Students nearing their clinical finals adopt a rather more focused approach: racing around the wards examining “the massive liver in bed 4”, “the wheezy chest in bed 9”, and the “rather embarrassing rash in the sideward”, grabbing a quick coffee while firing questions at each other about the causes of finger clubbing and the side effects of amiodarone, then fitting in a couple of children and a mad person before lunch Keen students who spend more time on the wards seeing patients and learning about conditions for themselves often benefit from impromptu, informal teaching from junior doctors who can teach during the course of completing their ward work Following a junior doctor on call is very valuable experience and is often the best way to see a general mix of cases Students need to be around when things happen if they are not only to learn but to experience the excitement and satisfaction of clinical medicine A group of students once reported on their experience in these words: Our teaching was really, really good from house officers right through to consultants So much time and effort was put in for us at all hours of the night and day, so much so that some of us learnt some important skills like how to read electrocardiograms (ECGs) in the early hours of the morning on take in the hospital 108 Learning medicine Spending an evening with the registrar in the accident and emergency department on the front line, seeing patients brought in by ambulance or referred by local GPs, is far more interesting for most students than standing at the back of an operating theatre, craning your neck, and still not being able to see what the surgeon is doing and getting flustered when you are shouted at for getting in the way or because you have momentarily forgotten the anatomical borders of Hasselback’s triangle A night in casualty I remember my first night in casualty as a medical student as one of the most exciting times of my whole medical training My placement in what is properly called accident and emergency medicine was relatively early in my time at medical school so, although I felt that my knowledge was minimal, my enthusiasm levels had never been higher; how many other students would be excited at the prospect of spending all of Friday night doing college work? The department resembled Piccadilly Circus, in all senses, especially noise and smell There was a constant flow of people milling here and rushing there, lying on trolleys, sitting on floors, banging on the wall, singing in the toilet, crying in the corner, or sleeping in the waiting room; men, women, children, patients, relatives, doctors, nurses, porters, receptionists, radiographers, a couple of burly 109 Medical school: the later years policemen and a rather conspicuous and obvious plain clothed detective, and to cap it all two nuns looking for a missing mother superior As well as the large number of walking wounded, an increasing proportion of whom as the night wore on and the pubs closed became staggering wounded, there were a couple of cases which I think I will never forget as they showed me medicine in all its glory A lovely lady in her 80s was brought in by ambulance, acutely short of breath and looking extremely distressed and scared She had heart failure and her lungs were filling up with fluid as her heart could no longer pump effectively Within minutes the junior doctor I was following around had put in a drip and was giving her some drugs which I had learnt about only a few weeks before in a tutorial As I stood by her bed filling in the blood forms trying to help out a bit, she started to get her breath back and soon was able to talk to me Within an hour she had managed to tell me her whole life story, including her several boyfriends during the war, the relevance of which to her medical history I still find hard to grasp, but she insisted it was important About a.m a young man of my age was rushed in from a road traffic accident, having been knocked off his motorcycle at high speed He was unconscious and had several broken bones Seemingly out of nowhere an enormous group of doctors and nurses appeared in the resuscitation room and pounced on the man, but with awe inspiring calm and organisation; it really was like watching an episode of Casualty, except that on television you get a better view than you when you are right at the back of a group of frantically busy people and you are trying not to get in the way By 3.30 a.m everything had quietened down somewhat, though the waiting area was still half full The motorcyclist was in theatre having one of his fractures screwed together, and the sweet old lady with an interesting history was apparently soundly asleep on a ward, one of the lucky few not having to stay on a trolley in casualty I wandered off to bed exhausted and exhilarated; the doctors and nurses carried on seeing patients How, I wondered, will I ever know what to and be able to treat people as well as they did, and, more worrying, how will I be able to stay awake that long? GR One of the most valuable experiences towards the end of training, which most schools encourage, is a period of several weeks shadowing a junior doctor This usually occurs in medicine, surgery, or obstetrics and may take place in a general hospital away from the medical school This allows only one or two students to be placed in each location, maximising their exposure to patients and teaching, and giving the opportunity for close supervision as clinical skills such as bladder catheterisation or intravenous cannulation are practised 110 Learning medicine First delivery I was woken up by the sound of my bleep It was barely a.m., and I had been asleep for less than hours By the time I had wearily put on my shoes and rushed to her cubicle, she had already begun to push Jane, the midwife, decided that there was not time for me to put on a gown, so I just put on the gloves The mother to be began to scream as the contractions became stronger and with each push the baby descended further I placed my left hand on the head as the crown appeared to stop it rushing out too quickly, while supporting the mother with my right I could almost feel my heart thumping against my chest Any remaining signs of tiredness had now completely disappeared in all the excitement Here I was minutes away from helping to bring a new life into the world It all went so quickly after that First the baby’s head appeared, and I pulled it down gently to release the anterior shoulder The rest appeared to come out all by itself It was 4.36 a.m precisely, and a big baby boy was born The mother cried with joy as I placed him on her tummy It’s an amazing feeling The family wouldn’t let me go until they had taken a photograph of me holding him in my arms By the time I had helped the midwife clear the mess and made sure all was well, it was way past a.m Time to get some sleep FI 111 Medical school: the later years The clinical subjects The major subjects to be learnt are general medicine and general surgery, and these are often studied in several blocks throughout the later years Increasingly, the emphasis is on core clinical skills rather than an encyclopaedic knowledge of different disciplines The boundaries between “subjects” are blurred and they are learned in a more integrated way and examined in integrated clinical examinations If they are not integrated, and as medicine and surgery become ever more specialised, the best general experience is often achieved by rotating through several firms covering a range of subjects as well as being around when the firm is “on take” (the team responsible for general admissions on that day) An weeks medical attachment may involve a fortnight each of chest medicine, infectious diseases, endocrinology, and cardiology A similar rotation in surgery could include gastrointestinal surgery, vascular surgery, urology, and orthopaedics Generally, students are split into small groups and allocated to a particular firm in the relevant speciality The firm is the working unit of hospital medicine and usually comprises a consultant or professor, one or two specialist registrars (who qualified several years before and are in training for that speciality), a senior house officer (who is usually a couple of years out of medical school and may be wanting to follow that speciality or may be in training for general practice or may just be drifting waiting for inspiration), and a house officer (who is newly qualified and will try and whisper the answers to the boss’s questions to you, which is generally why you will get them wrong) 112 Learning medicine The patients in hospital (inpatients) under the care of that team also provide the teaching subjects for the students and are shared out between the students, who are expected to talk to their patients and examine them before being taught on ward rounds or teaching sessions by the senior members of the team In the past much of this teaching was in the form of humiliation; ritualistic grillings of students in front of patient and colleagues alike, in the style of Richard Gordon’s character Sir Lancelot Spratt and his blustering, “You boy! What’s the bleeding time? Speak up Speak up” While the occasional medical dinosaur can still be found eating a brace of medical students for lunch, it is no longer acceptable today and is much less likely to occur The student who has taken the effort to prepare for such teaching can gain enormous benefit from seeing a condition he or she has previously only read about being illustrated in flesh and blood, making far easier the committing to memory of facts and figures as they suddenly take on real meaning and significance The use of community-based services as resources for learning is growing in all schools, some at a faster rate than others For example, Bristol now has a series of clinical academies across the West Country in Bath, Swindon, and Taunton for instance, where students spend several months at a time on attachment to various teaching firms As more care passes from hospital to community, such as in mental illness or child health, and as hospital stays tend to be much shorter, such as after having a baby or having day surgery, students are having to go to where the patients are GPs are playing an increasing part in undergraduate teaching of clinical skills, such as examination of body systems, in addition to their traditional role of teaching consultation skills and health promotion Insight can also be gained into a broader spectrum of disease and social problems than is apparent in hospitals, learning to deal appropriately with minor everyday illnesses or major personal upheavals that affect people’s lives A day in general practice My practice starts the day with a team meeting A coffee fix gives everyone time to label the important events of the next few days The builders are in, so all hearts will have a continuous murmur today; a new software package will be demonstrated to allow current problems to be highlighted while listing previous diagnoses, but will it really help? 113 Medical school: the later years Instantly I am involved, my opinion sought in a warm welcome to the group I ask what book I should read to learn about general practice and am told Middlemarch by George Eliot Six months later, having read the book, I am still thinking about what was meant by that answer In return, they ask me what skills a doctor should have in general practice Everyone joins in, and the discussion leads us into seeing the patients Today I see the patients on my own first I receive more trust and responsibility from these doctors in a week than in a year at the hospital Presenting the complaint and my thoughts to the GP is excellent practice at developing a “problem-oriented approach” I am daunted by the impossibility of knowing the person and their history in 10 minutes, and hospital clerkings are little preparation The long relationship between GP and patient is such a privilege and opportunity for appropriate intervention relevant to the patient’s needs and wishes I think through the messages I learnt from watching myself on video being “consulted” by actors back at the St Mary’s department of general practice The skills are those of good listening, while considering the possible background to the presenting problem – the family problems, alcoholism – and the needs, articulated or unspoken, for caring, a further specialist opinion, or a prescription I remember the advice that a holistic viewpoint and the availability of complementary therapies can obviate the need for drugs as psychological props for either doctor or patient Mr A has low back pain and was given short shrift by the orthopaedic consultant for not having sciatica that would be worth operating on, entirely ignoring his pain We talk about his weight, posture, and stress at work and re-emphasise his need for exercises and a good chair, which seems more appropriate Ms B comes in with severe abdominal pain and iliac fossa pain and rebound tenderness My excitement at a possible hospital referral dies down as the doctor reassures both of us that this is constipation The case mix is so different in a teaching hospital; a sense of proportion is vital and can come only with experience Mr C was found to be hypertensive opportunistically at a previous visit, and the nurse has confirmed this subsequently We discuss what this implies for his future health and treatment, and the doctor and I talk afterwards about current concepts in the management of blood pressure from both personal care and population health perspectives Every person is different and requires integrating and understanding of the possible pathologies with what is realistic in their life Without time or fast investigations nearly every diagnosis may be provisional; “come back tomorrow” is not a cop-out but good management In the corridor we have a “kerbside” case conference about what to with Ms X She has many problems, and all the partners have been to visit her at one time or other The latest news is not good, and, although she has heart failure, it is her mobility and risk of hip fracture that we worry about We visit her before lunch, assess her cardiovascular 114 Learning medicine and neurological status, and find out how well the carers are coping It may be that improving the lighting will counter her drowsiness and prevent a disastrous fall Over lunch we discuss strategies and priorities in looking after someone with diabetes and the implications for GPs of the new National Health Service (NHS) changes The balance has swung away from clinical freedom; doctors have lost much control over their time and decisions but to quite an extent are being forced to what they would have liked to anyway, namely more work on prevention and health promotion Computerisation has been unavoidable but as yet wastes far more time than it saves There is great potential for clear presentation of patient information and for networking outcomes between patients and practices for audit and research I sit in quietly as another partner runs a yoga class in her lunchbreak and feel greatly refreshed for the afternoon Later on, I join the local community psychiatric nurse One of the people we visit has panic attacks when she goes outside The nurse has given her mental exercises to at home and a routine to use when she feels the panic attack developing We take her out for a walk calmly and get along without her anxiety becoming panic, which encourages her greatly Another woman has gradually become more depressed since her husband died, and the nurse is delighted that she has a chance to intervene with counselling and cognitive therapy before a doctor (not from my practice!) has filled her full of tricyclic antidepressants A third has Alzheimer’s disease, and the issue is whether she will leave the frying pan on and burn the house down while her son is out at work Back at the practice I get on my bike to go home, overwhelmed by the breadth of insight needed in this work The loneliness in the consulting room is more than compensated by the warmth of genuine teamwork and equal exchange of views and approaches Humanity and pathophysiology mix after all TA The major clinical subjects in addition to medicine and surgery are also taught in a similar fashion: obstetrics (the care of pregnant women) and gynaecology (the speciality devoted to diseases confined to women); paediatrics (child health); and psychiatry (the care of patients with mental illness) Other specialities occupy a smaller part of the students’ time, and only a general understanding is required as detailed knowledge is beyond the scope of basic general medical training These include neurology (disorders of the motor and sensory function of the brain, spinal cord, and peripheral nerves); rheumatology (medical disorders of joints such as arthritis); genitourinary 115 Medical school: the later years medicine (sexually transmitted diseases which may involve the study and care of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS)); dermatology (skin diseases); ophthalmology (eye diseases); ear, nose, and throat surgery; and anaesthetics, which also covers pain management An attachment in the accident and emergency department is one of the most popular parts of the course for most students The glamorous image portrayed by television series is never all it is cracked up to be, but the excitement level is generally high, especially when there is the chance to be a useful pair of hands, suturing a laceration, helping the nurse put a plaster cast on the broken arm of a wriggling year old, or providing chest compressions during a resuscitation At some stage in the later years a more detailed approach to pathology is required, and this may take the form of a block of lectures, tutorials, and practicals or may be covered throughout the later years alongside the relevant clinical attachments The subjects studied under the heading of pathology are chemical pathology (the biochemical basis of diseases); histopathology (the macro and microscopic structure of diseased tissues); 116 Learning medicine haematology (the diseases affecting blood and bone marrow); microbiology (combining the study of bacteria, viruses, and other infectious organisms); and immunology (the role of the immune system in disease) Without a knowledge of these disease processes it is difficult to understand clinical signs and symptoms and to interpret the results of laboratory tests which play a crucial part in diagnosis and management of patients Other topics are fitted in as the course progresses including clinical pharmacology and therapeutics (the prescribing of drugs to treat illness), palliative medicine (the care of the dying), medical law and ethics, more advanced communication skills such as breaking bad news and bereavement counselling, and sometimes personal care (how to look after yourself with all the physical and emotional stresses and strains of being a doctor) and basic management skills An increasing number of medical schools also give students a general introduction to complementary and alternative medicine, so that as doctors they may have at least some insight into their 117 Medical school: the later years patients’ choices and also consider whether some aspects, such as acupuncture, might become a useful adjunct to their own practice The aim of the later years is to build on the basic knowledge and skills learnt in the early years and to add to that the necessary attitudes and skills in decision making, coping with uncertainty, and dealing effectively with patients, relatives, and colleagues that patients should expect of a good doctor The elective As well as the special study modules which allow each student choices in the precise content of their course, and the opportunity to learn how to study in greater depth, all schools set time aside in the later years of the course for what is known as the elective period This is usually between and 12 weeks long and is an opportunity for a student to undertake any medically related study at home or abroad Most students take the chance to travel and see medicine being practised in a very different setting whether in a trauma unit in down town Washington DC, the Australian Flying Doctor Service, or a children’s immunisation clinic in a canoe in Sarawak Some students carry out research while on elective or gain experience of a subject to which they have only limited exposure in their undergraduate course such as learning difficulties or tropical diseases The British Medical Journal offers a different sort of opportunity through the Clegg scholarship for electives working in medical journalism The excerpts that follow show just how diverse the choice of elective can be A “local” elective – Newcastle My elective was based at a NHS GP practice in Newcastle, which has good professional relationships with various complementary therapists in the local area I was given the opportunity to visit each of the therapists and obtained practical experience of the use of a number of complementary therapies including Traditional Chinese Medicine and Acupuncture, Herbal Medicine, Homeopathy, Naturopathy, Aromatherapy, Chiropractic, Osteopathy, Yoga, Tai-Chi, Reflexology, Hypnotherapy, Shiatsu, Biofeedback, Spiritual Healing, Bi-Aura Therapy, Magnetic Therapy and Crystal Therapy I was able to meet patients who had experienced various therapies and obtain their perspectives on whether a particular treatment had proved to be beneficial for them 118 Learning medicine A typical day during my elective involved spending the morning sitting in with a GP during surgeries to understand how complementary therapies can be integrated into primary care I noticed that the GP took a holistic approach to medicine, focusing on the whole person and not just their symptoms He has adopted various strategies to promote health and prevent disease such as ensuring all his asthma patients have peak flow meters and lending out blood pressure monitors to patients He prescribed some herbal remedies and nutritional supplements such as isphagula husk for constipation The surgery session was followed by a seminar on the concept of adopting a holistic approach to health and disease These seminars covered a variety of topics including nutrition, music therapy, energy medicine, the use of complementary therapies in cancer care, and Ayurvedic medicine After the seminar, I would spend the rest of the day with one of the therapists, for example a Homeopath I was able to spend time with two homeopaths in Newcastle observing them with patients and talking to patients about their experiences with homeopathy The homeopaths took a detailed history from their patients including their current problems, past medical history, current medication and diet and lifestyle choices They focussed on gaining an understanding of the whole person The patients were then prescribed homeopathic remedies designed to help relieve their symptoms The homeopaths said that they had a lot of success treating children with skin conditions such as eczema, acne and psoriasis The patients I met said that they generally felt better after their treatment However, there is little scientific evidence to show that homeopathic medicines are effective, largely due to the fact that there have been relatively few high quality clinical trials Many critics of homeopathy argue that its effectiveness in treating individual patients is largely due to the placebo effect, but the homeopaths counter this with the fact that homeopathic treatment has been shown to be effective in animals On completion of my elective, I feel that I have a greater understanding of the potential uses of complementary therapies, the procedures involved, and the associated benefits and risks I hope this will make me better prepared to support patients who are using or who are interested in using complementary and alternative medicine LH An elective abroad – Kilimatinde Hospital, Great Rift Valley, Tanzania Although I had a wonderfully interesting elective, which opened my eyes to a remote part of the world I didn’t know existed, my first time on the ward was pretty unpleasant It smelt like a farm I later found that this was because the hospital cows were kept next door I also saw a rat on the ward round and couldn’t help draw parallels between 119 Medical school: the later years rats in Tanzania and the constantly reported MRSA in the UK Although I went into theatre on a few occasions I did not assist as I assessed the HIV risk to be too high I was amazed to see that the only intra-operative observations were heart rate and manual blood pressure readings every five minutes The dedicated staff at the hospital worked tremendously hard with amazing commitment and went to great lengths to not only teach us but also to learn from us One of the best moments in this respect was when a lady with angina came to OPD I taught them how we would treat it but the concept of life long medication is totally alien there and we ended up prescribing aspirin for a month and propranolol for a week I hoped that, if we proved it would work, the patient would be willing to pay for long term medication One of the doctors later bumped into her in the village and she was apparently amazed that all her symptoms had gone in a day! My worst time at the hospital came ten days into my stay when I was confronted with a dead baby who had been brought by her parents with an infected umbilical cord after a home birth As the baby was unwrapped from her mothers back I found myself hesitating about the “diagnosis” It was highly unnerving to observe the almost blasé attitude of the staff, but I later concluded that this was a solid sense of reality; also perhaps a survival mechanism In three years of medicine in the UK I had never seen a youngster die After just three weeks in Tanzania I had seen four The mother carried the baby home for burial and I realised how time and energy consuming grief is in the UK, compared to here Severe burns were another common problem in the hospital This was unsurprising as most people cooked on open fires in otherwise poorly lit rooms These burns were simply treated with some pain relief and Vaseline gauze One particularly memorable case was that of Edward who, despite having sustained third degree burns and possible inhalation injury, made a fantastic recovery By the end of our elective he was a far happier boy than when we arrived and would roar with laughter when I, the “mzungu”, tickled his uninjured left arm A mzungu is a “white European traveller” and although not wholly courteous it is far better than the Maasai word: The Maasai christened travellers iloridaa enjekat – “those who confine their farts’’ DRC Assessments and examinations Schools adopt different systems of assessing students’ clinical progress Most combine end of attachment assessments with a final Bachelor of Medicine (MB) examination at the end of the course, which were traditionally taken in one grand slam but are increasingly now divided up into different parts over a year or longer The final MB consists of different sections in pathology, 120 Learning medicine medicine, surgery, clinical pharmacology and therapeutics, and obstetrics and gynaecology The “minor” speciality attachments are included in the major subjects The amount of emphasis placed on each varies, and within each the emphasis is on the ability to reason and use knowledge rather than to function as a mixture between a sponge and a parrot Some schools prefer almost total continuous assessment with each examination contributing to the final MB Others continue to put major emphasis on finals with the regular assessments being used to monitor progress and certify satisfactory attendance and completion of an attachment An increasing number of schools split finals into two, with the written papers taken a year earlier than clinicals, to encourage concentration on clinical skills and decision making before becoming a house officer The final MB comprises multiple choice questions, extended answers to structured questions, or essays, and practicals In medicine (which includes paediatrics and psychiatry), surgery, and obstetrics and gynaecology considerable emphasis is placed on the clinical bedside examination, which tests skills in talking to patients, eliciting the relevant clinical signs, and making a diagnosis Oral examinations are also held in most subjects Clinical skills are increasingly being tested in a more systematic way through Objective Structured Clinical Examinations (OSCEs) A few minutes are spent by all ... burly 109 Medical school: the later years policemen and a rather conspicuous and obvious plain clothed detective, and to cap it all two nuns looking for a missing mother superior As well as the large... time I had helped the midwife clear the mess and made sure all was well, it was way past a.m Time to get some sleep FI 111 Medical school: the later years The clinical subjects The major subjects... become a useful adjunct to their own practice The aim of the later years is to build on the basic knowledge and skills learnt in the early years and to add to that the necessary attitudes and